Treating juvenile idiopathic arthritis to target: Recommendations of an international task force
Ravelli, Angelo; Consolaro, Alessandro; Horneff, Gerd; Laxer, Ronald M.; Lovell, Daniel J.; Wulffraat, Nico M.; Akikusa, Jonathan D.; Al-Mayouf, Sulaiman M.; Antón, Jordi; Avcin, Tadej; Berard, Roberta A.; Beresford, Michael W.; Burgos-Vargas, Ruben; Cimaz, Rolando; De Benedetti, Fabrizio; Demirkaya, Erkan; Foell, Dirk; Itoh, Yasuhiko; Lahdenne, Pekka; Morgan, Esi M.; Quartier, Pierre; Ruperto, Nicolino; Russo, Ricardo; Saad-Magalhães, Claudia; Sawhney, Sujata; Scott, Christiaan; Shenoi, Susan; Swart, Joost F.; Uziel, Yosef; Vastert, Sebastiaan J.; Smolen, Josef S.
(2018) Annals of the Rheumatic Diseases, volume 77, issue 6, pp. 819 - 828
(Article)
Abstract
Recent therapeutic advances in juvenile idiopathic arthritis (JIA) have made remission an achievable goal for most patients. Reaching this target leads to improved outcomes. The objective was to develop recommendations for treating JIA to target. A Steering Committee formulated a set of recommendations based on evidence derived from a systematic
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literature review. These were subsequently discussed, amended and voted on by an international Task Force of 30 paediatric rheumatologists in a consensus-based, Delphi-like procedure. Although the literature review did not reveal trials that compared a treat-to-target approach with another or no strategy, it provided indirect evidence regarding an optimised approach to therapy that facilitated development of recommendations. The group agreed on six overarching principles and eight recommendations. The main treatment target, which should be based on a shared decision with parents/patients, was defined as remission, with the alternative target of low disease activity. The frequency and timeline of follow-up evaluations to ensure achievement and maintenance of the target depend on JIA category and level of disease activity. Additional recommendations emphasise the importance of ensuring adequate growth and development and avoiding long-term systemic glucocorticoid administration to maintain the target. All items were agreed on by more than 80% of the members of the Task Force. A research agenda was formulated. The Task Force developed recommendations for treating JIA to target, being aware that the evidence is not strong and needs to be expanded by future research. These recommendations can inform various stakeholders about strategies to reach optimal outcomes for JIA.
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Keywords: juvenile idiopathic arthritis, outcomes research, treatment, Rheumatology, Immunology and Allergy, Immunology, General Biochemistry,Genetics and Molecular Biology
ISSN: 0003-4967
Publisher: BMJ Publishing Group
Note: Funding Information: 7. Treatment should be adjusted until the target is achieved. Indirect evidence suggests that early clinical response or the achievement of CID is associated with improved long-term outcome.9 10 62 It is, thus, likely that pursuing the best possible target through treatment adjustment improves prognosis. Some participants argued that the word ‘adjusted’ sounds ambiguous and that ‘modified’ or ‘escalated’ could be more appropriate. It was, however, noted that the term adjustment covers both the modification and escalation of therapy. Several Task Force members emphasised the importance of non-pharmacological interventions, particu-larly physiotherapy and occupational therapy, optimisation of bone health, management of pain and psychological support. A concern was also raised that some targets may not be achievable for patients living in low-income coun-tries, where costly biological DMARDs may not be available or affordable; however, others noted that the adaptation of treatment would have to be done with those options that are available. This recommendation was supported by 100% of the participants. Publisher Copyright: © 2018 Article author(s). All rights reserved.
(Peer reviewed)